The Fate of Gynecological Oncology
The role of a gynecologic (GYN) oncologist is evolving, partly due to medical advances in the field, including the use of neoadjuvant chemotherapy and sentinel lymph node mapping.1 Gynecologic oncologists are also engaging in more benign gynecology responsibilities and teaching than in the past, revealing the need to better define their scope of practice.2
The Society of Gynecologic Oncology (SGO) hosted an interactive session at the SGO 2023 Annual Meeting on Women’s Cancer titled “The Future is Now: Determining the Fate of Gynecological Oncology,” during which participants offered input to help define the role of a gynecologic oncologist.1
Consultant360 asked SGO President and Director of Gynecologic Oncology at Mount Sinai Health System, Stephanie V. Blank, MD, questions about the symposium and the future of the field.
Consultant360: Please provide us with an overview of the learning objectives from "The Future is Now: Determining the Fate of Gynecological Oncology” at SGO 2023:
Stephanie Blank, MD: At the end of this session, we hope learners will be able to describe some of the changes that have happened within the profession of gynecologic oncology and begin to discuss the different paths forward. And there is not going to be one path forward. The aim of the session is to engage in discussion and help decide as a society where we want to go because it is a very diverse specialty. It’s really a subspecialty. What can we do to best serve all our members? Not just a few, but all of them.
C360: What is the role of a gynecologic oncologist within the patient care team and how has that evolved over time?
Dr Blank: Great question. We had the summit during the fall -- several GYN oncologists from across the country convened.3 One of the first things that we decided upon was a definition of a GYN oncologist. The important part of it is that we focus on comprehensive, longitudinal care of people with or at increased genetic risk of gynecologic malignancies. The role is really being able to deal with this in a comprehensive way using lots of different modalities.
[The role of a GYN oncologist might encompass] multiple disciplines, and it is over time, not just seeing the patient once, and you are done with it. We are not technicians. We are managing people over time, comprehensive care, and multi-modality. We know how to look at computerized tomography scans for our patients. We know how to manage the toxicities of our patients' chemotherapy. We know how to help them with their palliative care. We know how to deal with their psychological needs. It is sort of 360-degree, maybe more than that. It is three-dimensional. It is like a spherical approach to the patient.
C360: How does the role of a gynecologic oncologist change depending on the type of cancer the care team is treating? For example, cervical cancer vs endometrial cancer.
Dr Blank: Sure. In some cases, a patient might not need such longitudinal care. In early disease, if somebody has surgery and is cured, and say, lives far away from a GYN oncologist, they might not feel the need for such comprehensive, longitudinal care if it is three hours away. That is one situation. In endometrial cancer, even if someone does have an earlier disease, they might need to come back and develop a real survivorship plan. For example, if part of their cancer is related to obesity, then part of their survivorship plan may be talking about obesity, why it is important to work on that, how their biggest health risk is actually cardiac disease as a result of their obesity, and really using this as a teaching point.
You actually can capture the patient’s attention during that conversation because they're worried about their cancer. Maybe they will be motivated to lose weight. With cervical cancer, oftentimes you are involving multi-modalities, and then you are, in some ways, the captain of the ship because they are getting surgery, chemo, and radiation. And there are long-term effects of these treatments and a lot of times they are working with gynecologic oncologists for that. With some treatments, it is just treat, goodbye, you're done. But sometimes there are long-term effects of treatment and the gynecologic oncologist deals with that as well.
C360: What would you say are the perceived strengths, weaknesses, opportunities, and threats for clinicians in this subspecialty?
Dr Blank: One of the first things we did at our summit was a SWOT analysis.3 I can tell you what we saw as the strengths were again, our focus on this comprehensive, longitudinal care. We saw our expertise and our real focus on specific conditions. Within departments, we offer a lot in terms of training. There are not that many GYN oncologists. We are a very close-knit community, so that does a lot for us. That is just a small summation of our strengths. In terms of weakness right now, we are being pulled in so many different ways that it is very hard for us to define our role. One thing that I have not mentioned yet is we are being asked a lot to do a lot of benign surgery, and asked to do a lot of obstetric backup.
Some people are doing less and less systemic therapy because our systemic therapies are getting more and more complex. There are a lot more complex side effects and complex pharmacology. And if you're doing 15 cases a week, it might be hard to manage that, so some people are doing a bit less of that. And so we do not know what we are supposed to do. We're being pulled in all different directions. We are also getting pulled into different roles of departments. We are doing much more teaching than before. We are involved in other committees. We are getting pushed and pulled all over the place, and we are getting opportunities to define ourselves and decide where we want to go. That is a huge opportunity. And threats are, we are going to have a problem if we do not define ourselves. If we do not define ourselves, somebody else will, and it might not be what we want. We really have to take control here. And there are obviously a lot more nuances in there, but that is sort of a general gist of the picture.
C360: What action items are needed in the short and long term to preserve the subspecialties' mission of providing comprehensive, longitudinal care for people with gynecological cancers?
Dr Blank: We have been trying to work on that. We just published a paper with initial thoughts and some things that we have been talking about. We are putting together tools for people to go to their administration to demonstrate the role and value of a GYN oncologist. There is a lot of downstream revenue that every GYN oncologist generates, and we do not have those numbers at the ready. So we are trying to actually get a hold of that type of data so that people have it to present to their administration. In terms of obstetric backup, we are all doing it more and more, and we are not reimbursed for it. It is not necessarily in their contracts. We are trying to make a business case for that as well. These are just some of the things. We want to be able to really have resources for our members to take to their administration.
We are finding that a lot of our members do not feel very valued by their departments, and we really need to give them the tools to negotiate their value. Another area that is bigger than GYN oncology is our concern about the long-term effects that this is having on the whole profession of obstetrics and oncology in terms of education and the fact that many gynecologists are referring their benign cases to GYN oncology. That's why we're doing more and more teaching. We have actually been in a lot of conversations with all of the big organizations in obstetrics & gynecology (OB/GYN). I think we are working on that level as well. And that is a larger issue
C360: What would you say are the overall take-home messages from our conversation today?
Dr Blank: The take-home message is there has been a change. Change is not bad, but we have to take charge of it. We have to decide what we want, and not everyone will want the same thing. I think it is really important that people do not think about what they want individually, but think about what they want the profession to be. So, even if one person does not want to give chemotherapy, should GYN oncologists be able to give chemotherapy? Yes. We have to think about that. And we have to be able to make a case for that because if we give that up, we are not going to be able to take comprehensive, longitudinal care of our patients.
If you think about the trends, our surgery is getting less radical. Our systemic treatments are getting better and better. We can still do surgery, but we need to understand these other pieces of it. I do think it is really important for us to sort of think about it and if you think about it in terms of the patient, it makes perfect sense. Do not think about it in terms of yourself. Think about it in terms of the whole profession. What is so great about this profession? It is really the care we take. I think that that is a really good way to think about it.
C360: Is there anything else that you'd like to add today, Dr Blank?
Dr Blank: There is so much. The whole idea, when this specialty formed, was all about GYN oncologists can do it all. But some things we do all the time and some things we do not. There was a time when a GYN oncologist felt like he or she had to do everything because they were a GYN oncologist. But if you do a urinary conduit twice a year, are you the right person to do that procedure? Not necessarily. I do not think we need to necessarily do everything to say we do everything anymore. Maybe somebody is wonderful at that, but not everybody should feel that they have to be. It is not only that referral patterns have changed, I mean our treatments are better. That's wonderful. That's one of the reasons why our surgery is different. Training is different for OB/GYNs. That's another piece of it. We can't fix everything. So, we're starting at GYN oncology.
If you are doing so much GYN surgery that you cannot treat your patients with cancer, then that is a problem because that she be our primary focus. I think that is where you need to be able to have the tools to talk to the people who are causing this problem to fix it. I mean, you have to think about what you want, and maybe you do just want to be in the operating room and not giving chemotherapy, and that's fine. We can work with that, as well. This is not to disparage anyone or to say anyone is less than anyone else. But GYN oncologists should be able to perform the tasks that the whole big profession of GYN oncology is meant to do. We are trying to fix that.
- Presidential Matters: Stephanie V. Blank. Society of Gynecologic Oncology. Published February 22, 2023. Accessed March 23, 2023. https://www.sgo.org/news/presidential-matters-stephanie-v-blank/
- Blank SV, Huh WK, Bell M, et al. Doubling down on the future of gynecologic oncology: The SGO future of the profession summit report. Gynecol Oncol. 2023;171:76-82. doi:10.1016/j.ygyno.2023.02.008
- FOP Chairs. Society of Gynecologic Oncology. Accessed March 23, 2023. www.sgo.org/wp-content/uploads/2023/02/SGO-Future-of-the-Profession-Taskforce.pdf